Kristen Shirey

Trauma history and depression predict incomplete adherence to antiretroviral therapies in a low income country.

Background As antiretroviral therapy (ART) for HIV becomes increasingly available in low and middle income countries (LMICs), understanding reasons for lack of adherence is critical to stemming the tide of infections and improving health. Understanding the effect of psychosocial experiences and mental health symptomatology on ART adherence can help maximize the benefit of expanded ART programs by indicating types of services, which could be offered in combination with HIV care. Methodology The Coping with HIV/AIDS in Tanzania (CHAT) study is a longitudinal cohort study in the Kilimanjaro Region that included randomly selected HIV-infected (HIV+) participants from two local hospital-based HIV clinics and four free-standing voluntary HIV counselling and testing sites. Baseline data were collected in 2008 and 2009; this paper used data from 36 month follow-up interviews (N = 468). Regression analyses were used to predict factors associated with incomplete self-reported adherence to ART. Results Incomplete ART adherence was significantly more likely to be reported amongst participants who experienced a greater number of childhood traumatic events: sexual abuse prior to puberty and the death in childhood of an immediate family member not from suicide or homicide were significantly more likely in the non-adherent group and other negative childhood events trended toward being more likely. Those with incomplete adherence had higher depressive symptom severity and post-traumatic stress disorder (PTSD). In multivariable analyses, childhood trauma, depression, and financial sacrifice remained associated with incomplete adherence. Discussion This is the first study to examine the effect of childhood trauma, depression and PTSD on HIV medication adherence in a low income country facing a significant burden of HIV. Allocating spending on HIV/AIDS toward integrating mental health services with HIV care is essential to the creation of systems that enhance medication adherence and maximize the potential of expanded antiretroviral access to improve health and reduce new infections.

The effect of antidepressant treatment on HIV and depression outcomes: results from a randomized trial.

Background:Depression is a major barrier to HIV treatment outcomes. Objective:To test whether antidepressant management decision support integrated into HIV care improves antiretroviral adherence and depression morbidity. Design:Pseudo-cluster randomized trial. Setting:Four US infectious diseases clinics. Participants:HIV-infected adults with major depressive disorder. Intervention:Measurement-based care (MBC) – depression care managers used systematic metrics to give HIV primary-care clinicians standardized antidepressant treatment recommendations. Measurements:Primary – antiretroviral medication adherence (monthly unannounced telephone-based pill counts for 12 months). Primary time-point – 6 months. Secondary – depressive severity, depression remission, depression-free days, measured quarterly for 12 months. Results:From 2010 to 2013, 149 participants were randomized to intervention and 155 to usual care. Participants were mostly men, Black, non-Hispanic, unemployed, and virally suppressed with high baseline self-reported antiretroviral adherence and depressive severity. Over follow-up, no differences between arms in antiretroviral adherence or other HIV outcomes were apparent. At 6 months, depressive severity was lower among intervention participants than usual care [mean difference −3.7, 95% confidence interval (CI) −5.6, −1.7], probability of depression remission was higher [risk difference 13%, 95% CI 1%, 25%), and suicidal ideation was lower (risk difference −18%, 95% CI −30%, −6%). By 12 months, the arms had comparable mental health outcomes. Intervention arm participants experienced an average of 29 (95% CI: 1–57) more depression-free days over 12 months. Conclusion:In the largest trial of its kind among HIV-infected adults, MBC did not improve HIV outcomes, possibly because of high baseline adherence, but achieved clinically significant depression improvements and increased depression-free days. MBC may be an effective, resource-efficient approach to reducing depression morbidity among HIV patients.

Prevalence of psychological trauma and association with current health and functioning in a sample of HIV-infected and HIV-uninfected Tanzanian adults

Background In high income nations, traumatic life experiences such as childhood sexual abuse are much more common in people living with HIV/AIDS (PLWHA) than the general population, and trauma is associated with worse current health and functioning. Virtually no data exist on the prevalence or consequences of trauma for PLWHA in low income nations. Methodology/Principal Findings We recruited four cohorts of Tanzanian patients in established medical care for HIV infection (n = 228), individuals newly testing positive for HIV (n = 267), individuals testing negative for HIV at the same sites (n = 182), and a random sample of community-dwelling adults (n = 249). We assessed lifetime prevalence of traumatic experiences, recent stressful life events, and current mental health and health-related physical functioning. Those with established HIV infection reported a greater number of childhood and lifetime traumatic experiences (2.1 and 3.0 respectively) than the community cohort (1.8 and 2.3). Those with established HIV infection reported greater post-traumatic stress disorder (PTSD) symptomatology and worse current health-related physical functioning. Each additional lifetime traumatic experience was associated with increased PTSD symptomatology and worse functioning. Conclusions/Significance This study is the first to our knowledge in an HIV population from a low income nation to report the prevalence of a range of potentially traumatic life experiences compared to a matched community sample and to show that trauma history is associated with poorer health-related physical functioning. Our findings underscore the importance of considering psychosocial characteristics when planning to meet the health needs of PLWHA in low income countries.

Prevalence of Psychiatric Symptoms/Syndromes in Medical Settings

Mental health and substance use disorders, or behavioral health (BH) disorders, are common and associated with significant morbidity, disability, and health-care costs. However, BH services are not adequate to meet this need. BH care in the general medical sector has increased substantially in the last decade. However, such care tends to lack adequate evidence-based mental health treatment despite a growing evidence base. Moreover, behavioral and medical conditions tend to co-occur, and thus, patients with combined needs are often seen in medical settings. BH and medical conditions are risk factors for one another, and each complicates the course and treatment of the other. Based on these observations, it is essential that we integrate mental health and medical care delivery to improve access, care, and reduce cost.

Ongoing life stressors and suicidal ideation among HIV-infected adults with depression

BACKGROUND Suicidal ideation is the most proximal risk factor for suicide and can indicate extreme psychological distress; identification of its predictors is important for possible intervention. Depression and stressful or traumatic life events (STLEs), which are more common among HIV-infected individuals than the general population, may serve as triggers for suicidal thoughts. METHODS A randomized controlled trial testing the effect of evidence-based decision support for depression treatment on antiretroviral adherence (the SLAM DUNC study) included monthly assessments of incident STLEs, and quarterly assessments of suicidal ideation (SI). We examined the association between STLEs and SI during up to one year of follow-up among 289 Southeastern US-based participants active in the study between 7/1/2011 and 4/1/2014, accounting for time-varying confounding by depressive severity with the use of marginal structural models. RESULTS Participants were mostly male (70%) and black (62%), with a median age of 45 years, and experienced a mean of 2.36 total STLEs (range: 0-12) and 0.48 severe STLEs (range: 0-3) per month. Every additional STLE was associated with an increase in SI prevalence of 7% (prevalence ratio (PR) (95% confidence interval (CI)): 1.07 (1.00, 1.14)), and every additional severe STLE with an increase in SI prevalence of 19% (RR (95% CI): 1.19 (1.00, 1.42)). LIMITATIONS There was a substantial amount of missing data and the exposures and outcomes were obtained via self-report; methods were tailored to address these potential limitations. CONCLUSIONS STLEs were associated with increased SI prevalence, which is an important risk factor for suicide attempts and completions.

Child and caregiver concordance of potentially traumatic events experienced by orphaned and abandoned children

Exposure to trauma is associated with significant emotional and behavioral difficulties among children. Overall, reports of trauma and violence experienced by children are discrepant from those of their caregivers. Even less is known about the extent of concordance between orphans and their caregivers. This study examines the correlates of concordance in reported traumatic experiences between 1269 orphaned and abandoned children (OAC) and their caregivers. The OAC lived in family-settings in five low- and middle-income countries (LMICs) and were part of a longitudinal study, “Positive Outcomes for Orphans” (POFO) that enrolled children aged 6 to 12 at baseline. By examining concordance with respect to specific types of trauma reported, this study expands the understanding of who reports which types of traumas experienced by OAC, thereby improving the potential to provide targeted interventions for children who have experienced such events. In this study, children and caregivers were asked separately if the child had experienced different types of potentially traumatic events (PTEs). Children were significantly more likely to report physical abuse, sexual abuse, and family violence than were caregivers. Caregivers were significantly more likely than children to report natural disasters and accidents. High levels of concordance were found in the reporting of wars, riots, killings, and deaths in the family. The impacts of trauma on behavior and mental health are profound, and highly effective interventions targeting sequelae of childhood trauma are currently being developed for use in low-resource areas. Findings from this study demonstrate that it is feasible to conduct screening for PTEs utilizing child self-report in resource limited settings and that child self-report is crucial in evaluating trauma, particularly family violence and physical or sexual assault.

Suicide and HIV

Suicidal ideation, attempts, and completions are common among people living with HIV/AIDS (PLWHA). Recent cohort studies have found that the rate of suicide completion among PLWHA in Switzerland is three times that of the general population, and, in the USA, one in five HIV positive patients report having had suicidal ideation in the previous week. Many factors contribute to this phenomenon, including highly prevalent comorbid depression, substance use disorders, social isolation, stigma, and chronic pain and fatigue associated with the disease. During the early years of the HIV epidemic, suicide rates in the USA and Western Europe were extremely high, particularly among men. With the advent of combination antiretroviral therapy (cART), and resultant prolonged life expectancy, suicide rates have declined and are now similar to those of other populations living with chronic medical illnesses such as amyotrophic lateral sclerosis, end-stage renal disease, and spinal cord injury. However, even with the decline in suicide rates since the 1990s, suicidal ideation and behaviors remain alarmingly high among PLWHA, and it is urgent for providers caring for this population to evaluate and address suicide risk in routine clinical practice.

Symptoms of depression among patients attending a diabetes care clinic in rural western Kenya

Objective The prevalence of diabetes in sub-Saharan Africa is rising, but its relationship to depression is not well-characterized. This report describes depressive symptom prevalence and associations with adherence and outcomes among patients with diabetes in a rural, resource-constrained setting. Methods In the Webuye, Kenya diabetes clinic, we conducted a chart review, analyzing data including medication adherence, hemoglobin A1c (HbA1c), clinic attendance, and PHQ-2 depression screening results. Results Among 253 patients, 20.9% screened positive for depression. Prevalence in females was higher than in males; 27% vs 15% (p = 0.023). Glycemic control trends were better in those screening negative; at 24 months post-enrollment mean HbA1c was 7.5 for those screening negative and 9.5 for those screening positive (p = 0.0025). There was a nonsignificant (p = 0.269) trend toward loss to follow-up among those screening positive. Conclusions These findings suggest that depression is common among people with diabetes in rural western Kenya, which may profoundly impact diabetes control and treatment adherence.

Factors Associated with Change in Sexual Transmission Risk Behavior over 3 Years among HIV-Infected Patients in Tanzania

Background The reduction of HIV transmission risk behaviors among those infected with HIV remains a major global health priority. Psychosocial characteristics have proven to be important correlates of sexual transmission risk behaviors in high-income countries, but little attention has focused on the influence of psychosocial and psychological factors on sexual transmission risk behaviors in African cohorts. Methodology and Principal Findings The CHAT Study enrolled a representative sample of 499 HIV-infected patients in established HIV care and 267 newly diagnosed HIV-infected individuals from the Kilimanjaro Region of Tanzania. Participants completed in-person interviews every 6 months for 3 years. Using logistic random effects models to account for repeated observations, we assessed sociodemographic, physical health, and psychosocial predictors of self-reported unprotected sexual intercourse. Among established patients, the proportion reporting any recent unprotected sex was stable, ranging between 6–13% over 3 years. Among newly diagnosed patients, the proportion reporting any unprotected sex dropped from 43% at baseline to 11–21% at 6–36 months. In multivariable models, higher odds of reported unprotected sex was associated with female gender, younger age, being married, better physical health, and greater post-traumatic stress symptoms. In addition, within-individual changes in post-traumatic stress over time coincided with increases in unprotected sex. Conclusions and Significance Changes in post-traumatic stress symptomatology were associated with changes in sexual transmission risk behaviors in this sample of HIV-infected adults in Tanzania, suggesting the importance of investing in appropriate mental health screening and intervention services for HIV-infected patients, both to improve mental health and to support secondary prevention efforts.

AIDS and Trauma: Adults, Children and Orphans

Though HIV/AIDS has become more of a chronically-managed illness in the most well-off of places, it is still a devastating disease that spreads rapidly and silently. Biomedical and behavioral research conducted over the last 25 years has taught us a tremendous amount about HIV: the people it infects, the way it infects and the damage it reaps. While some of this research is headline news, particularly those discoveries that lead us closer to a vaccine or other biomedical prophylaxis like microbicides, and to a lesser extent behavioral research that teaches us about effective prevention efforts, what are infrequently discussed but are no less important are the very substantial effects that trauma has on those infected and affected by HIV. We have found that there are higher rates of past and current trauma in adults infected by HIV than in the general population and subsequently these adults often have higher rates of substance abuse and other high risk activities. In children orphaned and otherwise affected by AIDS, we see they suffer not just the loss of a parent, but also significant emotional wounds that require specific treatments to heal. HIV is more than a virus; it is a disease that exploits already present vulnerabilities like poverty and goes on to wreak havoc on all levels of society. In this chapter, we will talk about trauma and its relationship to HIV in both adults and children. We will use fictitious case studies starting in childhood and moving through adulthood to explicate the complicated life stories, specifically the significant role trauma plays in the lives of people who are affected by HIV.